As the hepatitis A outbreak continues to spread in New Hampshire, health officials are reminding the public that there’s a safe and effective vaccine against the contagious liver disease.
Since the state health department declared the outbreak last November, 232 cases of hepatitis A have been reported here, and one person has died. Cases have been reported in every county, with most of them in the more populated counties of Hillsborough, Strafford, Merrimack and Rockingham.
“We are seeing about six to seven (new cases) a week right now,” said Elizabeth Daly, chief of the bureau of infectious disease control for the New Hampshire Department of Health and Human Services.
Those most at risk continue to be drug users, homeless people, men who have sex with men and those with direct contact with infected individuals, Daly said.
But if you don’t fit into one of those categories, it doesn’t mean you may not be at risk, health officials say. “Any one of us can be exposed to it because of the way the virus is spread,” said Bobbie Bagley, director of public health and community services in Nashua. “You don’t have to inject IV drugs. You can eat food that was prepared by an individual who may not have washed their hands after going to the bathroom.”
Hepatitis A is spread by oral contact with a tiny amount of fecal matter from an infected person. And that means there’s a small, but real, chance you could become ill without realizing it.
About 60% of the cases have been people who report substance use, Daly said, and about a quarter have been people who are, or have been, homeless. “So it all has to do with having this close contact with one another, not having the ability to have good hygiene,” she said. “And then they get the virus in their mouth and it then goes to their gastrointestinal tract and infects their liver.”
Daly said the state is working to increase access to the hepatitis A vaccine, which she said is both safe and effective. She said the 13 public health networks across the state have provided more than 2,000 doses of vaccines at more than 80 different immunization events since May 1.
Bagley said her agency took proactive steps to prevent hepatitis A infections after other states began reporting cases in the summer of 2018. “We started to increase our outreach efforts and our vaccination of individuals who had substance use disorders,” she said.
The health department’s outreach van has been visiting sites such as soup kitchens and shelters; information about the hepatitis A vaccine was given out on social media, radio and in newspaper spots as well as at community meetings; and a “block party” was held last summer to make the vaccine available.
“Any opportunity that we had, we pushed the information out to encourage that vaccination to protect the public,” Bagley said.
There have been 23 cases of hepatitis A confirmed in Greater Nashua, which includes the city and 12 surrounding towns, she said.
Daly said about half of those who have been diagnosed with hepatitis A in the current outbreak are also infected with hepatitis C, a different virus that causes liver damage. That includes the one person who has died in the hepatitis A outbreak, she said. ”Because if you already have hepatitis C, your liver already can have damage, and so it will have a harder time recovering from the hepatitis A,” she said.
The two illnesses have similar names and symptoms, including fever, abdominal pain, diarrhea and jaundice. But there are key differences.
The hepatitis C virus (HCV) is spread through exposure to infected blood and blood products. Risk factors include sharing needles when using illegal drugs; receiving a blood transfusion or organ donation from an infected individual; being born to an infected mother; a needle stick with a dirty needle (through tattooing, ear piercing or, for medical professionals, needle exposure on the job); and sexual contact with someone who is HCV-positive.
There’s no treatment for hepatitis A, other than what health providers call “supportive care,” but there is the vaccine. It’s the reverse for hepatitis C: There’s no vaccine, but there is an effective treatment.
Most people infected with HCV do not exhibit symptoms and might not know they have it, but 75% to 85% of them go on to have chronic infection that can lead to liver disease many years later, Daly said. “That’s why it’s important to be tested so you can get diagnosed and get this very effective treatment, so that you can clear your infection and then not go on to potentially have these long-term health consequences like cirrhosis, cancer and death,” she said.
Her agency also focuses on preventing infection among intravenous drug users; about 85% of the reported hepatitis C cases here involve people who previously reported having injected drugs. “So using sterile syringes if you’re not already infected will protect you, and if you are already infected, will protect others,” Daly said.
Philip Alexakos, chief operations officer at the Manchester health department, said his agency has given more than 700 hepatitis A vaccines since Jan. 1, with a focus on at-risk populations, including people who recently have been incarcerated, those who have been homeless, and those who use recreational drugs.
People sharing marijuana joints, cigarettes or even food can spread the virus, Alexakos said. And the virus persists on surfaces, which increases the risk in close quarters. “That’s why, when you have group living arrangements, that puts people at potential risk, especially when they have other risk factors,” he said.
The Manchester health department has purchased a mobile health van that will help outreach workers bring vaccines and screening tests into the community; it should be on the road by year’s end, Alexakos said. ”That will help meet people where they’re at and reduce the burden of transportation,” he said.
Daly said such outbreaks typically last for 18 months before the numbers start to decline. “We’re expecting we’re in this for the long haul, and we probably have another nine months to a year left of seeing this increase in cases,” she said.
When someone is diagnosed with hepatitis A, the health department does an assessment to see if there is any potential risk to the wider community. If so, the health department would alert the public and offer vaccines, Daly said.
That’s what happened in 2013, when two employees at a Contoocook restaurant were diagnosed; the health department held vaccination clinics for patrons who had eaten at the restaurant. Among those who lined up for vaccines were then-Gov. John Lynch and Dr. Jose Montero, who was then the director of public health.
“Something like that could happen at any moment due to this outbreak,” Daly said.
Some of the earliest cases here were individuals who traveled to other states where outbreaks had already occurred, including some who had attended music festivals and then returned to New Hampshire, unwittingly bringing the virus with them, Daly said. “It just takes these types of introductions and then it’s in the population, where it can spread really easily,” she said.
But, she said, there’s no cause for alarm. “Anyone who wants to be protected can seek out this vaccine,” Daly said. “It offers lifelong immunity and protection.”
Alexakos said hepatitis A vaccine is now routinely given to children in New Hampshire. And he recommends adults talk with their health care providers about getting vaccinated. “Because we know it’s out there, ... there is that potential that somebody who’s ill and doesn’t know it might be working either in food service or child care and would expose other people,” he said. “It’s not a high percentage or a high risk, but it’s certainly preventable, and weighing a lot of the pros and cons it certainly behooves folks to err on the side of protection.
“And wash your hands,” he added.